Wyeth’s Prempro, a menopause treatment, is displayed on the shelf at a pharmacy in Cambridge, Mass., in 2006.
A full 72 percent of women experiencing menopausal symptoms have not received treatment for them, according to a new survey by the Endocrine Society. The poll, conducted in mid-April, also found that 60 percent of women exhibiting symptoms of menopause have not talked to their primary health providers about possible treatment.
The statistics prompted the Endocrine Society and its Hormone Health Network to develop a so-called Menopause Map — an interactive online quiz that helps women and their doctors discuss what treatment options (hormonal or nonhormonal) might be the most effective for them.
Menopausal women who are about to or have already stopped menstruating may also experience hot flashes, sweating, insomnia, mood swings, fatigue, depression and vaginal dryness, among others. Although the tool does not encourage women to pursue one avenue of treatment over another, it prompts women to consider a range of options to alleviate menopausal symptoms, including hormone therapy.
Hormone replacement therapy, or HRT, a once widely used treatment option for menopause symptoms, came under fire in 2002 after a government-commissioned study, the Women’s Health Initiative, found that hormone therapy could increase the risk of blood clots, stroke, breast cancer and heart attacks. But in the past few years, while some studies have continued to find that hormone therapy increases the likelihood of a host of health risks in patients, other trials have pointed to the effectiveness of hormones in treating menopause symptoms in women in their 50s.
For more perspective, we turn now to Dr. Cynthia Stuenkel, an endocrinologist specializing in menopause at the University of California, San Diego, and a member of the Endocrine Society who contributed to the creation of the new tool. The questions and responses were lightly edited for length.
One of the most confusing pieces of information for women’s health in the last couple of years has been hormone replacement therapy. What were women doing to treat menopause before 2002, and what happened that year?
Stuenkel: Before 2002, doctors and health care professionals not only used hormone therapy to treat women’s menopause symptoms, they also believed hormones would provide women with a way to prevent heart disease, osteoporosis, bone fractures, and possibly cognitive decline and dementia. In 2002, the Women’s Health Initiative sponsored a study, which did not seek to say whether hormones would help women feel better, since we already knew that. The point of the study was to ask whether these hormones were going to be effective at prevention in women in their 50s, 60s and 70s because our current guidelines at the time suggested that we should be offering hormones to all these women, and the results showed that the risks of hormone therapy exceeded the benefits.
The risks were things like heart attacks, stroke, blood clots and breast cancer. And because of these findings, there was a dramatic decrease in the number of hormone therapy prescriptions written. At the time, I think a lot of women and health care professionals that take care of women just said, “This seems too negative, too threatening, and too scary.”
Did a lot of women stop taking hormone therapy in 2002? Did they resort to other treatments, or did they stop seeking them?
Stuenkel: There was definitely a drop in therapy. Folks who chart prescriptions detected as much as a 60 to 70 percent reduction in the number of prescriptions for hormone therapy. However, some women looked to other therapies that had been once prescribed to women who should not have been on hormone therapy. Some of these are antidepressants or agents for nerve pain like Gabapentin, which are not as effective as hormone therapy but can certainly offer some relief of hot flashes, for example.
What has been going on in hormone therapy research since then?
Stuenkel: Over the last 10 years, we’ve had added follow-up with those participants of the original Women’s Health Initiative from 2002, and we have had to further analyze the 2002 findings and to take a close look at different age groups and at different outcomes. Our current thinking is that for healthy women in their 50s — women who have not had breast cancer or a history of blood clots — and have been experiencing the symptoms of menopause for less than 10 years, hormone therapy can be very effective for symptom relief and overall is quite safe.
Why were the outcomes between the 2002 study and the recent study so different?
Stuenkel: I think it was looking at the absolute numbers that made the difference. The Women’s Health Initiative said there’s an increase in risk of stroke, and that was scary. However, when we analyzed the numbers, we realized that for a woman in her 50s, the risk of stroke is about 2 per 10,000 women per year taking hormones. There are a number of women that say, “I’m not taking any risk; that is absolutely too high for me.”
We also looked at the scary question of breast cancer, and we also teased out the numbers and looked at what the risks were. We looked at women in their 50s and tried to see if 3 in 1,000 women will develop breast cancer in a year, how many more will develop it if they take hormone therapy? We realized that the number for combined hormone therapy would mean one more woman would develop breast cancer in a year, so 4 in 1,000. The question is whether a woman can live with that number. For some women, that number is way too high. But again, it has to be an individual decision, and I think women need to be made aware of this so that it is an informed decision and not a decision by indecision.
What spurred the Endocrine Society to create this tool?
Stuenkel: The Endocrine Society decided to create this Menopause Map, an interactive online tool, because of an April poll that the Endocrine Society put together that reported that 7 out of 10 symptomatic menopausal women weren’t getting anything in the way of treatment. What I thought was even a little bit more disturbing was that 2 out of 3 women said that they hadn’t discussed treatment options with their doctors.
Why is it significant that 72 percent of women aren’t getting treatment? What does it mean for women and women’s health?
Stuenkel: It depends on how they’re feeling with their hot flashes. Some women are not particularly bothered. Some women sail through, and although they can be annoying, the hot flashes don’t get in their way. And then other women are more debilitated and suffer from sleep disruption and irritability, and they find that their effectiveness in their daily activities can be compromised. So I think that for those women, therapy can be very beneficial.
You mentioned earlier that 2 out of 3 women haven’t talked to their doctors about this. Why aren’t women talking to their doctors about these symptoms?
Stuenkel: I’m not sure I know the answer to that question, but I can hypothesize that they might feel like hormones aren’t safe for them and that there is not much to be discussed. A lot of women seem reluctant to initiate these kinds of conversations. So this is our goal with the Menopause Map. We wanted to give women a tool they can put their answers into and print out. We’ve included a list of questions for women to discuss with their doctors about their symptoms and their options for therapy.
Do you think some of the reason why women aren’t talking to their doctors about this is because of the confusion out there regarding the treatment of menopause?
Stuenkel: There’s certainly confusion as to what to believe. A study might come out today and another might come out tomorrow and contradict the previous study. I think women are wondering what the truth is. I think another reason why women might not be reaching out to their doctors about this is a matter of competing priorities. At midlife, women start developing more health issues like blood pressure, blood sugar or other gynecologic issues that might arise. In the short period of time that can be allotted for some health appointments, it just might not seem that important to them, so they might not bring it up.
What is the goal of this online quiz?
Stuenkel: The goal was to help women be aware of their symptoms, be aware of their risks, personal preferences. (It’s also) to introduce them to the menu of options women have available to them if they want them. Our goal was to have something we can give women — something they can print out, take with them and hopefully be a way to stimulate, encourage, empower this conversation with their doctor or health care professional so that women are having these conversations and making educated decisions. Our main idea is to hopefully get the conversation about menopause back on the map.
How exactly does it work?
Stuenkel: The interactive quiz on hormone.org gives women options depending on their lifestyles and characteristics. Depending on the answers a woman gives, the website might tell her that she’s doing great and might suggest that she exercise or stop smoking. The website might tell another woman, depending on her answers, that she should have something checked out by a health care professional before she can go forward and consider any treatments. Another woman might see a number of different choices to treat her symptoms. I think laying it out in a menu format can be helpful. The website includes options for women who might exhibit very few menopause symptoms, women who have a history of breast cancer, cardiovascular risk, or blood clots. It covers some of the real-life situations that women find themselves in.
What advice would you give to women in menopause or about to enter menopause?
Stuenkel: I think the most important thing is for women to be in touch with their own body symptoms and what is happening to them. No. 2, they should be aware of their other health priorities at the time and how those may factor in. And No. 3 would be to know their options. I think having a choice is much better than not being fully informed. I would like to see women more armed at making decisions about what makes the most sense for them at midlife. I think it is also important for women to understand that it is worth it to try different therapies for a short period of time to see what works for them. I know new information is continuously coming forth, and that is why it is essential for women to start these conversations with their doctors.